Personal Accident Claim Form

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1 Personal Accident Claim Form Accident & Sickness

2 Guidance Notes Accident and Sickness Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would therefore ask you to answer all questions (dashes and spaces cannot be accepted). You should read and sign the declaration. If you are unable to supply any of the requested documents, please include a separate note explaining why this is, to enable us to help you more quickly. IMPORTANT: PLEASE READ CAREFULLY Please answer all the questions in FULL and in BLOCK CAPITALS. Section A has to be completed by YOU. Please ensure that you sign the Claim Form. Section B has to be completed by your DOCTOR. Any charge for completion of this section is your responsibility. Section C has to be completed by YOU, after you have read the notes explaining your rights under the Access to Medical Reports Act Please ensure that all relevant questions are answered, and that all appropriate sections and boxes are completed. Failure to do so may delay the processing of your claim. The form when fully completed must be returned to your Insurance Broker, who arranged this insurance for you. They will forward it to Towergate AIUA. Name & Address INSURANCE BROKER DETAILS Postcode Contact Name Tel. No. If the benefit is to be used for the provision of a replacement worker, please support with evidence of expenditure SECTION A: To be completed by the claimant If you are unable to complete this form personally, due to your disability, it may be completed on your behalf. Policy No. Policyholders Name Insured Person s Surname (including any titles) of Birth Occupation(s) Address Postcode Tel. No. Please state you average gross weekly wage, calculated over the 12 months prior to the commencement of disability. If you are claiming for temporary total or temporary partial disablement, please provide payslips or copy accounts confirming details of your Gross Weekly wage for the 52 week period prior to the date of the accident or onset of the sickness. Please state the date from which you have been unable to attend your normal occupation? Have you ever suffered from this or any connected disability prior to the insurance commencing? Yes No if yes please provide full details, including dates. Are you still totally incapacitated as a result of your accident/sickness? Yes No if no please provide the date that you were able to undertake a) part of your duties b) all of your duties.

3 PLEASE PROVIDE FURTHER DETAILS OF THE NATURE OF YOUR DISABILITY AS APPROPRIATE ACCIDENT/SICKNESS ACCIDENT - and time of Occurrence, Please describe the circumstances leading to your accident, SICKNESS - upon which symptoms first appeared, Please describe the nature of your sickness, Please provide the name and address of the Doctor who attended you. Please provide the name and address of your usual Doctor (if different). When did you first seek medical attention in relation to your disability? During what period have you been confined to hospital? From To What is your expected date of return to work? Full name and address of employer at the commencement of disability. Have you previously claimed benefits under this insurance? Yes No If Yes, please provide full details. Are you covered for benefits for your disability under any other insurance? Yes No If Yes, please provide full details. I/We understand that in handling this claim, Towergate AIUA (a trading name of Towergate Underwriting Group Ltd) will act on behalf of the insurer(s) and that I/we confirm our informed consent to the claim being handled on this basis. I understand that the making of a fraudulent claim by providing untrue information is a criminal offence likely to lead to prosecution. I confirm that the information given on this form is to the best of my knowledge and belief, true in every respect and that I have declared and not claimed amounts refunded to me or claimed from any other source. You must read the declaration before signing Signature If you are not the insured person, please state your relationship to them.

4 SECTION B: To be completed by your Doctor The claimant must obtain at his or her own expense the following Certificate from a qualified and Registered Medical Practitioner. Are you the usual Medical Attendant of the claimant? Yes No If Yes, how long have you been so? On what date did you first attend upon claimant for his/her present disability? On what date did you first sign claimant as unfit for work? Please confirm the nature of the sickness or injury sustained, together with details of the precise diagnosis and treatment being given Has the claimant suffered from this or any other associated complaint, prior to this period of disability? If Yes, please give the dates and types of treatment Yes No Treatment At the time of the accident or commencement of sickness was the claimant suffering from any other sickness or disease? Yes No If Yes, please give details with medication prescribed and advise whether this will retard recovery of present disability Is the disability caused by or traceable to any gradually developing bodily deterioration? Yes No If Yes, please provide full details including original date of onset Is the disability due to Human Immunodeficiency Virus (HIV) and/or any HIV related sickness, any psychiatric, mental or nervous disorder, mental sickness, anxiety, stress or depression, self inflicted injury, drug abuse, pregnancy or childbirth related conditions? Yes No If Yes, please provide details continued

5 When do you expect claimant to return full duties? When do you expect claimant to return partial duties? If the claimant has already returned to work please state the date and whether he/she was able to return to all, or just part of his/her duties DECLARATION BY YOUR DOCTOR I confirm that that the claimant is/was under medical attention, and was totally prevented from working for remuneration or profit from his/her normal occupation from to Doctor s Signature Doctor s Official Stamp Doctor s Name (BLOCK CAPITALS)

6 ACCESS TO MEDICAL RECORDS ACT 1988 In accordance with the Act and before we can apply for a medical report from your doctor, we need you consent. Before signing in the space below, you should know that you have certain rights under the Access to Medical Records Act These are set out below: (A) (B) (C) (D) You can withhold your consent. You can see the report before it is sent to us or during the six months after that. You can ask the doctor if he will amend any part of the report, which you consider to be incorrect or misleading. If the doctor is not in agreement, you may append your comments. The doctor can withhold from you the report, or part of it, if he/she thinks you would be harmed by seeing it. CONSENT TO OBTAIN MEDICAL REPORT Name of Insured Person: Address: of Birth: Post Code: I/We understand that in handling this claim, Towergate AIUA (a trading name of Towergate Underwriting Group Ltd) will act on behalf of the insurer(s) and that I/we confirm our informed consent to the claim being handled on this basis. I understand that the making of a fraudulent claim by providing untrue information is a criminal offence likely to lead to prosecution. I confirm that the information given on this form is to the best of my knowledge and belief, true in every respect and that I have declared and not claimed amounts refunded to me or claimed from any other source. I have been informed of my statutory rights under the Access to Medical Records Act In connection with my insurance claim hereby consent to Towergate Undewriting Personal Accident & Travel and/or their Agents instructed to deal with this claim on their behalf, being provided with medical information from any doctor; who at any time, has attended me concerning anything which affects my physical or mental health. I agree that a copy of this consent shall have the validity of the original. You must read the declaration before signing I wish to see the report before it is sent to the company (please tick) Yes No Signature Name of Doctor: Address: Post Code: Towergate AIUA, 8 Grove Park Court, Harrogate, North Yorkshire, HG1 4DP, tel: fax: , Towergate AIUA & Towergate Underwriting are a trading name of Towergate Underwriting Group Limited Registered Address: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Services Authority

7 Should your claim result in a payment being made, and you would prefer this to be paid by BACS rather than cheque, please complete the details below. IMPORTANT NOTICE TO ALL CLAIMANTS In the event of this claim being successful and payment authorised in your favour, the amount being claimed can be paid directly in to your bank account using Bank Automated Clearing Services (BACS). In order to do this the company will need your bank account details so please complete the form below (Block Capitals please). Name of Bank Branch Sort Code Account No. Account Name Towergate AIUA, 8 Grove Park Court, Harrogate, North Yorkshire, HG1 4DP, tel: fax: , Towergate AIUA & Towergate Underwriting are a trading name of Towergate Underwriting Group Limited Registered Address: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Services Authority

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